The analysis includes some unrealistic assumptions – such as
current health services being able to achieve 100% coverage of HIV testing –
and cannot be read as a simple prediction of future events. But it does
indicate the direction we should be aiming for.

If it were possible to provide HIV testing to all adults
(aged 15 to 64) every year, 5% of all future infections would be prevented –
due to the impact of HIV treatment on infectiousness. If it’s also assumed that
people diagnosed with HIV will have half as many sexual partners as before,
then 18% of infections would be prevented.

But the programme would be expensive, costing £80,000 per
quality-adjusted life year (QALY) gained. This means that it would cost £80,000
for each extra year that a person lives in good health.

An alternative scenario looked at the impact of annual HIV
testing for all members of key populations (men who have sex with men, black
African people and people who inject drugs), plus everyone else testing once.
This would prevent 4% of future infections, or 15% if diagnosed individuals
substantially changed their sexual behaviour.

As far fewer people would need to be tested, costs would be
much lower – £17,500 per quality-adjusted life year gained. This is highly cost-effective by UK standards.

HIV Prevention England and National HIV Testing Week aim to
increase the frequency with which gay men and black African people test for
HIV, rather than trying to achieve this across the whole population. This model
provides support for such a targeted approach.

PrEP: adherence and resistance

This finding comes from further analysis of the
Partners PrEP study, conducted in Kenya
and Uganda.
Whereas two other PrEP studies conducted with African women had disappointing
results due to poor adherence (FEM-PrEP and
VOICE),
this study conducted with heterosexual men and women showed that PrEP can be
effective. All participants in Partners PrEP were in long-term relationships
with a partner they knew had HIV – this
may have facilitated good adherence.

Over 3000 HIV-negative people took PrEP in the study and 29 of
them acquired HIV from their partner. The
new analysis examined drug levels in these 29 individuals and in a larger
group of participants who remained HIV negative.

Most people’s adherence was quite consistent – people who
took their pills regularly tended to continue to do so.

One concern about poor adherence to PrEP is drug resistance.
In other words, if a person is taking some (but not all) of their prescribed
doses of PrEP, becomes HIV positive and continues to take PrEP, could their
virus be resistant to tenofovir or FTC? These drugs are used both for PrEP and
for treatment of HIV infection.

Two participants had acquired HIV just before they began
PrEP, but their acute HIV infections were not recognised at the time. These two
men did develop resistance to FTC, but it did not persist after they stopped
taking the drug.

Moreover, analysis of blood samples from the 48 men who
became HIV positive after beginning
PrEP shows that none had resistance mutations or reduced phenotypic
susceptibility to the drugs used.

Different PrEP trials conducted with different populations
have found adherence to vary significantly. When its results are reported, PROUD,
the UK’s study of PrEP, will give us an insight into adherence among UK gay men.

In Taiwan,
HIV rates had been low in people who inject drugs until an epidemic rapidly
emerged in 2004. Within two years the government had implemented a programme of
methadone maintenance treatment and needle and syringe supplies, as well as
continuing to make HIV treatment freely available.

Analysis of recent HIV infections among people who inject
drugs entering prison (who are tested for HIV) shows that incidence has dropped
following implementation of the programme. Incidence was estimated to be 6% in
2004, 18% in 2005, 2% in 2007 and 0.3% in 2010.

Researchers also kept in contact with around 2500 prisoners
who were released under an amnesty in 2007. All had previously used heroin and
were HIV-negative at the time of release.

Incidence in individuals who received methadone maintenance
therapy was 0.1%, compared to 1% in those who did not receive it. Incidence in
people who frequently used needle and syringe exchanges was 0%, compared to
0.5% in people who did not use those services. It is likely that low viral
loads in people taking HIV treatment also contributed to these figures.

Methadone was an integral part of the Taiwanese programme –
it is a form of opioid
substitution therapy. By helping people reduce or replace their use of
heroin, crack and other drugs, fewer injections occur and equipment is shared
less often, resulting in fewer HIV infections.

A
second study this month compared two forms of opioid substitution therapy –
methadone and buprenorphine-naloxone. The latter did have some disadvantages –
a higher drop-out rate and an increase in sexual risk taking among males taking
it. But most importantly, both methadone and buprenorphine-naloxone were
equally effective in reducing the frequency of injecting and the sharing of
injecting equipment.

The sauna they work in is close to two motorways and
attracts men from across the North
West, many of whom are in long-term relationships
with women. Around half of those using the service have never had a sexual
health screen before but tend to be unwilling to go to a GUM clinic or their GP
for this. Moreover, many customers are in their fifties or sixties – the age
group in which many men are diagnosed with HIV late (with a low CD4 cell
count).

Body Positive have worked in the sauna for several years and
put GUM clinicians in touch with the sauna’s management. They worked together
to design a service that would suit the specifics of the environment and the
customers’ needs. Nurse-led outreach clinics are held every two weeks, offering
testing for chlamydia, gonorrhoea, syphilis, hepatitis B, hepatitis C and HIV.
Dr Martyn Wood says that a few years ago they couldn’t have offered this range
of tests during outreach. It has been made possible by recent improvements in
testing methods – nucleic acid amplification tests (NAATs), urine samples and
self-swabbing of the throat and rectum.

Clinics are held in a private room near areas used for sex
and socialising – the background music prevents discussions with clients from
being overheard but the low-level lighting can be challenging. Nurse Moira
Grobicki says that the clinics are popular – there is usually a queue and some
men come to the sauna especially on the day they take place. Customers
appreciate the clinic’s anonymity and convenience. Rather than just take a
rapid HIV test, most men prefer to have the full range of tests done and to receive
results a few days later, by text, email or phone call.

For
customers attending at other times, ‘do it yourself’ self-sampling kits are
offered and can be posted back to the GUM. The same range of tests is done,
with fingerprick blood samples used for HIV testing. While customers can ask
the sauna’s staff for a kit, they seem to be mostly distributed by Body
Positive on days when they are doing outreach without the nurses present. There
is less demand: for each man returning a self-sampling kit, five see a nurse.
It seems that while self-sampling may complement the outreach clinics, it won’t
replace them – a personal interaction is needed in this setting.

Editors' picks from other sources

The
Court found that Mr Golding understood both that he had the infection
and how it is transmitted, and by not preventing transmission – or
disclosing his condition thereby allowing the complainant to make an
informed decision whether or not she wanted to risk acquiring herpes –
was guilty of reckless grievous bodily harm under Section 20 of the
Offences Against The Person Act 1861.

Thirty years after the discovery of virus, new research from NAT (National AIDS Trust) reveals that gay men are in the dark about new HIV prevention tools, with knowledge among 16-24 year olds particularly low.

“Talk
to me like you talk to your friends when no one is around.” That was my
only request when I sat down with each of four HIV-negative gay men to
create a short film about their lives and attitudes. They
held back nothing, sharing details of their sex lives, their fears of
becoming infected, and, perhaps most surprising, what they really think
of HIV-positive guys.

aMASE (advancing Migrant Access to Health Services in Europe) is a European Commission funded study, led by researchers from University College London and the Institute of Health Carlos III in Madrid. A clinic-based survey, focused on HIV services, is being carried out in 40 clinics around Europe.

The aMASE community survey has now launched, focused on the barriers to accessing health care for migrant communities. The survey is open to all migrants, whether they are living with HIV or not. To take part you have to be aged 18 or over and living outside your country of birth.

It presents "the rationale and evidence for increasing HIV screening and testing...in order to support public health and sexual health professionals to establish and improve HIV screening and testing in medical and community services."

NAM is an award-winning, community-based organisation, which works from the UK. We deliver reliable and accurate HIV information across the world to HIV-positive people and to the professionals who treat, support and care for them.